Prognostic value of laparoscopic ultrasound in patients with gastro-esophageal cancer

Combined pretherapeutic endoscopic and laparoscopic ultrasonography may predict survival of patients with upper gastrointestinal tract cancer

BACKGROUND

The combination of endoscopic and laparoscopic ultrasonography (EUS-LUS) is accurate for resectability assessment of patients with upper gastrointestinal cancer (UGIC). But neither the ability of EUS/LUS to predict long-term prognosis nor the potential impact on patient survival using this selection strategy has been investigated. This prospective, single-center study evaluated whether pretherapeutic EUS-LUS stratification related to the prognosis in UGIC patients and whether patient selection by this strategy provided a prognostic outcome comparable with survival data from the literature.

METHODS

Each patient had a pretherapeutic tumor node metastasis (TNM) stage and a resectability assessment assigned based on EUS-LUS findings. Survival curves were constructed and compared for each of the EUS-LUS TNM stage and resectability groups at the end of the observation period. Finally, the R0 resection rate, median, and 5-year survival rates were compared with the literature.

RESULTS

This study enrolled 936 consecutive patients with esophageal (n = 256), gastric (n = 273), or pancreatic (n = 407) cancer. A statistically significant survival difference (p < 0.01) between the different TNM stages and resectability groups predicted by EUS-LUS was observed regardless of the cancer type. The poor prognosis for the patients with irresectable or disseminated UGIC was accurately predicted by EUS and LUS. The R0 resection rate as well as the median and 5-year survival rates were comparable with data from the literature.

CONCLUSION

The pretherapeutic EUS-LUS patient stratification related significantly to the final prognosis for UGIC patients. An EUS-LUS-based patient selection strategy seemed to provide a prognostic outcome similar to data from computed tomography (CT)-based populations.

Der laparoskopische Ultraschall

Laparoscopic ultrasound exploration has significantly augmented the range of minimally invasive surgery. In particular it is essential for 3D exploration of the abdomen for staging. Beyond its diagnostic, purposes laparoscopic ultrasound is gaining importance for intraoperative therapeutic support, e. g. imaging of the biliary tree during laparoscopic surgery of the bile duct and for navigation during radio-frequency ablative or resective interventions on the liver and other parenchymatous organs. Compared to other imaging procedures, sonography has still the highest potential for further development. The most progress can be expected in navigated ultrasound.

Staginglaparoskopie in der Onkologie

The availability of more treatment options for gastrointestinal cancer requires precise and reliable pretherapeutic staging. Despite impressive technical progress in modern imaging procedures, this high level of staging quality is not yet warranted in all instances. Visual exploration of the abdominal cavity in extended diagnostic laparoscopy (EDL), including surgical dissection of areas which are primarily inaccessible, biopsy retrieval, and laparoscopic ultrasound, is superior in the diagnostic workup of early peritoneal carcinomatosis and (small) liver metastases. It is helpful to evaluate lymph node infliction and local resectability. In esophageal carcinoma, pretherapeutic EDL is valuable in case of advanced adenocarcinoma of the distal esophagus (AEG I according to Siewert), whereas the incidence of abdominal tumor manifestations in squamous cell carcinoma is too low to perform staging laparoscopy. In advanced gastric cancer, EDL yields relevant additional information in up to 20% of cases. If a multimodal therapeutic strategy is considered, EDL should be obligatory at least in prospective therapeutic studies. In carcinoma of the pancreas, EDL is in general not recommended by the majority of centers. Selective use (in particular in advanced cancer with a high probability of local irresectability) is gaining importance. In hepatobiliary malignancy including colorectal metastases, the high yield of additional information by EDL was confirmed in recent studies.

The role of staging investigations for oesophago-gastric carcinoma

AIMS

To study the frequency with which unresectable disease was identified on pre-operative staging investigations in patients with oesophago-gastric carcinoma, and to audit whether a staging protocol had reduced the rate of exploratory surgery.

METHODS

Ninety-eight patients with oesophageal carcinoma, 89 patients with adenocarcinoma of the gastro-oesophageal junction (GOJ) and 68 patients with gastric carcinoma were staged according to a protocol of computerised tomography, laparoscopy and endoscopic ultrasound.

RESULTS

The frequency with which each investigation identified unresectable disease was as follows: (a) computerised tomography-oesophagus 12/67, GOJ 13/58, stomach 10/60; (b) laparoscopy-oesophagus 3/22, GOJ 5/45, stomach 8/23; and (c) endoscopic ultrasound-oesophagus 15/55, GOJ 3/30. By tumour location, rates of exploratory surgery were 1/18 for the oesophagus, 12/35 for the GOJ and 4/42 for the stomach. All of the staging failures in patients with GOJ carcinomas related to posterior tumour extension into the lesser sac.

CONCLUSIONS

Staging investigations precluded resection in one-third of patients, the greatest yield being for laparoscopy in gastric carcinoma. In spite of this, 18% of patients undergoing surgical intervention underwent exploratory surgery alone, notably patients with GOJ carcinoma.